Health Without Borders? Political Economy and Cultural Barriers to Equity in Ghana’s National Health Insurance Scheme
1
School of humanities, Social science and Law, University of Dundee, Dundee, Scotland, United Kingdom
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Ghana’s national health insurance scheme (NHIS), introduced in 2003 to replace the exclusionary user fee system known as cash-and-carry, was envisioned as a pro-poor mechanism for universal health coverage (Government of Ghana, 2003). Two decades later, active coverage remains below 50%, enrolment disproportionately favours wealthier groups, and insured households continue to face catastrophic health expenditures. this study explores why a scheme designed to promote equity and financial protection has produced exclusionary outcomes (Akazili et al., 2025; Shaniece, 2025).
METHODS:
a qualitative exploratory case study design was employed, guided by an integrated theoretical framework combining the health policy triangle (Grindle & Thomas, 1991) and grindle and thomas’s political economy of reform (Jones et al., 2021). data sources include semi-structured interviews with NHIS users, frontline staff, social welfare officers, and policymakers in two purposively selected districts in Ghana’s central region, complemented by a scoping review of literature from 2003 to 2025.
RESULTS:
findings from literature review and policy documents reveal two interconnected systemic challenges: first, a political economy dominated by elite capture(Aboagye et al., 2021), election-cycle short-termism (Akweongo et al., 2022; Umar et al., 2021), and governance failures that distort resource allocation and weaken pro-poor mandates (Fusheini, 2016); second, a cultural and structural mismatch where the scheme’s individualistic, bureaucratic design conflicts with Ghanaian communal norms and the irregular livelihoods of the informal sector majority.
CONCLUSIONS:
technical fixes alone cannot resolve these structural inequities. achieving NHIS’s foundational promise requires politically informed, culturally embedded reforms that address power asymmetries, leverage communal solidarities, and redesign implementation processes to reconcile policy intent with lived realities. this research offers an integrative lens for health systems scholarship and evidence-based pathways for realigning social health insurance with its mandate of health as a social right, not a privilege.
Ghana’s national health insurance scheme (NHIS), introduced in 2003 to replace the exclusionary user fee system known as cash-and-carry, was envisioned as a pro-poor mechanism for universal health coverage (Government of Ghana, 2003). Two decades later, active coverage remains below 50%, enrolment disproportionately favours wealthier groups, and insured households continue to face catastrophic health expenditures. this study explores why a scheme designed to promote equity and financial protection has produced exclusionary outcomes (Akazili et al., 2025; Shaniece, 2025).
METHODS:
a qualitative exploratory case study design was employed, guided by an integrated theoretical framework combining the health policy triangle (Grindle & Thomas, 1991) and grindle and thomas’s political economy of reform (Jones et al., 2021). data sources include semi-structured interviews with NHIS users, frontline staff, social welfare officers, and policymakers in two purposively selected districts in Ghana’s central region, complemented by a scoping review of literature from 2003 to 2025.
RESULTS:
findings from literature review and policy documents reveal two interconnected systemic challenges: first, a political economy dominated by elite capture(Aboagye et al., 2021), election-cycle short-termism (Akweongo et al., 2022; Umar et al., 2021), and governance failures that distort resource allocation and weaken pro-poor mandates (Fusheini, 2016); second, a cultural and structural mismatch where the scheme’s individualistic, bureaucratic design conflicts with Ghanaian communal norms and the irregular livelihoods of the informal sector majority.
CONCLUSIONS:
technical fixes alone cannot resolve these structural inequities. achieving NHIS’s foundational promise requires politically informed, culturally embedded reforms that address power asymmetries, leverage communal solidarities, and redesign implementation processes to reconcile policy intent with lived realities. this research offers an integrative lens for health systems scholarship and evidence-based pathways for realigning social health insurance with its mandate of health as a social right, not a privilege.
| eISSN: | 2654-1459 |
We process personal data collected when visiting the website. The function of obtaining information about users and their behavior is carried out by voluntarily entered information in forms and saving cookies in end devices. Data, including cookies, are used to provide services, improve the user experience and to analyze the traffic in accordance with the Privacy policy. Data are also collected and processed by Google Analytics tool (more).
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
